J Gastrointest Surg (2015) 19:1425–1432 DOI 10.1007/s11605-015-2870-8
ORIGINAL ARTICLE
Reduction of the Incidence of Delayed Gastric Emptying in Side-to-Side Gastrojejunostomy in Subtotal Stomach-Preserving Pancreaticoduodenectomy Toru Nakamura 1,2 & Yoshiyasu Ambo 1 & Takehiro Noji 2 & Naoya Okada 1 & Minoru Takada 1 & Toru Shimizu 1 & On Suzuki 1 & Fumitaka Nakamura 1 & Nobuichi Kashimura 1 & Akihiro Kishida 1 & Satoshi Hirano 2
Received: 3 February 2015 / Accepted: 30 May 2015 / Published online: 11 June 2015 # 2015 The Society for Surgery of the Alimentary Tract
Abstract Background One of the most common morbidities of pancreaticoduodenectomies is delayed gastric emptying (DGE). The recent advent of subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) attempts to lessen this troublesome complication; however, the incidence of DGE still remains to be 4.5–20 %. This study aims to evaluate whether the incidence of DGE can be reduced by the side-to-side gastric greater curvature-to-jejunal anastomosis in comparison with the gastric stump-to-jejunal endto-side anastomosis in SSPPD. Methods Between October 2007 and September 2012, a total of 160 consecutive patients who had undergone SSPPD were analyzed retrospectively. In the first period (October 2007–March 2010), gastrojejunostomy was performed with end-to-side anastomosis in 80 patients (SSPPD-ETS group). In the second period (April 2010–September 2012), gastrojejunostomy was performed with the greater curvature side-to-jejunal side anastomosis in 80 patients (SSPPD-STS group). The postoperative data were collected prospectively in a database and reviewed retrospectively. Results The incidence of DGE was 21.3 % in the SSPPD-ETS group and 2.5 % in the SSPPD-STS group (P=0.0002). According to the classification of the International Study Group of Pancreatic Surgery (ISGPS), the incidence of DGE of grades A, B, and C were 5, 5, and 7 in the SSPPD-ETS group and 0, 2, and 0 in the SSPPD-STS group, respectively. The overall morbidity and postoperative hospital stay of the two groups were not significantly different. Conclusions The greater curvature side-to-side anastomosis of gastrojejunostomy is associated with a reduced incidence of DGE after SSPPD. Keywords Delayed gastric emptying . Pancreaticoduodenectomy . Subtotal stomach- preserving pancreaticoduodenectomy . Gastrojejunostomy
Introduction In pancreaticoduodenectomy, delayed gastric emptying (DGE) frequently causes morbidity with the reported * Toru Nakamura [email protected] 1
Department of Surgery, Teine-Keijinkai Hospital, Teine-ku, Sapporo, Japan
2
Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
incidence ranging from 5 to 57 % in previous studies.1–8 Some have demonstrated that the antecolic route of duodenojejunostomy reduces DGE after pylorus-preserving pancreaticoduodenectomy.7,9–15 Recent reports and metaanalysis also show that preoperative diabetes, preoperative symptoms of gastric outlet obstruction, pancreatic fistulas, and postoperative complications are clinical risk factors for DGE; conversely, antecolic reconstruction and preoperative biliary drainage result in the reduction in DGE.16–18 To prevent DGE, subtotal stom ach-preserving pancreaticoduodenectomy (SSPPD) has been developed,19–21 and several clinical studies have demonstrated that it leads to a reduction of DGE.22–24 Contrary to this expected outcome, DGE still occurs in 21 % of SSPPD with antecolic gastrojejunostomy performed in our institution. To overcome this problem, the greater curvature side-to-jejunal side gastrojejunostomy has been attempted.
1426
This study evaluates whether DGE can be reduced when the greater curvature side-to-side anastomosis of gastrojejunostomy is undertaken for SSPPD reconstruction in comparison with the conventional end-to-side gastrojejunostomy.
Patients and Methods Patients Between October 2007 and September 2012, a total of 160 consecutive patients who had undergone SSPPD at Teine Keijinkai Hospital were analyzed retrospectively. In the first period (October 2007–March 2010), gastrojejunostomy was performed with end-to-side anastomosis in 80 patients (SSPPD-ETS group). In the second period (April 2010–September 2012), gastrojejunostomy was performed with the greater curvature side-to-jejunal side anastomosis in 80 patients (SSPPD-STS group). After the surgery, the patients were monitored until hospital discharge, and afterwards, they were followed up in the outpatient clinic for up to 90 days. All data were collected prospectively in a computerized database and reviewed retrospectively. Informed consent was obtained from all patients preoperatively; this study was conducted in accordance with the ethical standards of the Committee on Human Experimentation of our institution. DGE was diagnosed according to the classification of the International Study Group of Pancreatic Surgery (ISGPS)25 as follows: grade A if a nasogastric tube (NGT) was required between postoperative day (POD) 4–7, reinsertion of the NGT was necessary owing to nausea and vomiting after removal by POD 3, or inability to tolerate a solid diet by POD 7 but with resumption by POD 14; grade B if an NGT was required from POD 8–14, reinsertion of the NGT was necessary after POD 7, or the patient could not tolerate unlimited oral intake by POD 14 but was able to resume a solid oral diet by POD 21; and grade C if nasogastric intubation could not be discontinued or had to be reinserted after POD 14 or if the patient was unable to maintain unlimited oral intake by POD 21. Surgical Technique The schema of the SSPPD-ETS, the conventional group procedure, and the SSPPD-STS, the study group procedure, are shown in Fig. 1. The stomachs were divided 2–3 cm proximal to the pyloric ring with more than 90 % of the stomach preserved in both procedures.19 In brief, both reconstruction groups underwent end-to-side pancreaticojejunostomy and hepatojejunostomy, and the jejunal loop was used for the gastrojejunostomy via an antecolic route. In all the patients in this study period, the gastrojejunostomy was reconstructed with antecolic reconstruction. The singular difference between
J Gastrointest Surg (2015) 19:1425–1432
the two groups was that in the SSPPD-ETS group, the gastric stump was anastomosed to the jejunal loop in an end-to-side fashion (Fig. 1a), whereas in the SSPPD-STS group, the jejunal loop was anastomosed to the greater curvature 5–10 cm proximal to the closed gastric stump, and the anastomosis was just the greater curvature, not the anterior nor the posterior wall of the stomach (Fig. 1b). The gastrojejunostomy was performed by a one-layer anastomosis using the Gambee technique of 4-0 monofilament absorbable sutures. The stomach is severed with a stapler and is oversewn with serosa. The opening of the anastomosis for each technique is about 5 cm length; therefore, the STS and the ETS are of same orifice size. Both groups were managed according to the same clinical pathway, such as removal of the NGT if the drainage amount
ORIGINAL ARTICLE
Reduction of the Incidence of Delayed Gastric Emptying in Side-to-Side Gastrojejunostomy in Subtotal Stomach-Preserving Pancreaticoduodenectomy Toru Nakamura 1,2 & Yoshiyasu Ambo 1 & Takehiro Noji 2 & Naoya Okada 1 & Minoru Takada 1 & Toru Shimizu 1 & On Suzuki 1 & Fumitaka Nakamura 1 & Nobuichi Kashimura 1 & Akihiro Kishida 1 & Satoshi Hirano 2
Received: 3 February 2015 / Accepted: 30 May 2015 / Published online: 11 June 2015 # 2015 The Society for Surgery of the Alimentary Tract
Abstract Background One of the most common morbidities of pancreaticoduodenectomies is delayed gastric emptying (DGE). The recent advent of subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) attempts to lessen this troublesome complication; however, the incidence of DGE still remains to be 4.5–20 %. This study aims to evaluate whether the incidence of DGE can be reduced by the side-to-side gastric greater curvature-to-jejunal anastomosis in comparison with the gastric stump-to-jejunal endto-side anastomosis in SSPPD. Methods Between October 2007 and September 2012, a total of 160 consecutive patients who had undergone SSPPD were analyzed retrospectively. In the first period (October 2007–March 2010), gastrojejunostomy was performed with end-to-side anastomosis in 80 patients (SSPPD-ETS group). In the second period (April 2010–September 2012), gastrojejunostomy was performed with the greater curvature side-to-jejunal side anastomosis in 80 patients (SSPPD-STS group). The postoperative data were collected prospectively in a database and reviewed retrospectively. Results The incidence of DGE was 21.3 % in the SSPPD-ETS group and 2.5 % in the SSPPD-STS group (P=0.0002). According to the classification of the International Study Group of Pancreatic Surgery (ISGPS), the incidence of DGE of grades A, B, and C were 5, 5, and 7 in the SSPPD-ETS group and 0, 2, and 0 in the SSPPD-STS group, respectively. The overall morbidity and postoperative hospital stay of the two groups were not significantly different. Conclusions The greater curvature side-to-side anastomosis of gastrojejunostomy is associated with a reduced incidence of DGE after SSPPD. Keywords Delayed gastric emptying . Pancreaticoduodenectomy . Subtotal stomach- preserving pancreaticoduodenectomy . Gastrojejunostomy
Introduction In pancreaticoduodenectomy, delayed gastric emptying (DGE) frequently causes morbidity with the reported * Toru Nakamura [email protected] 1
Department of Surgery, Teine-Keijinkai Hospital, Teine-ku, Sapporo, Japan
2
Department of Gastroenterological Surgery II, Hokkaido University Graduate School of Medicine, Sapporo, Japan
incidence ranging from 5 to 57 % in previous studies.1–8 Some have demonstrated that the antecolic route of duodenojejunostomy reduces DGE after pylorus-preserving pancreaticoduodenectomy.7,9–15 Recent reports and metaanalysis also show that preoperative diabetes, preoperative symptoms of gastric outlet obstruction, pancreatic fistulas, and postoperative complications are clinical risk factors for DGE; conversely, antecolic reconstruction and preoperative biliary drainage result in the reduction in DGE.16–18 To prevent DGE, subtotal stom ach-preserving pancreaticoduodenectomy (SSPPD) has been developed,19–21 and several clinical studies have demonstrated that it leads to a reduction of DGE.22–24 Contrary to this expected outcome, DGE still occurs in 21 % of SSPPD with antecolic gastrojejunostomy performed in our institution. To overcome this problem, the greater curvature side-to-jejunal side gastrojejunostomy has been attempted.
1426
This study evaluates whether DGE can be reduced when the greater curvature side-to-side anastomosis of gastrojejunostomy is undertaken for SSPPD reconstruction in comparison with the conventional end-to-side gastrojejunostomy.
Patients and Methods Patients Between October 2007 and September 2012, a total of 160 consecutive patients who had undergone SSPPD at Teine Keijinkai Hospital were analyzed retrospectively. In the first period (October 2007–March 2010), gastrojejunostomy was performed with end-to-side anastomosis in 80 patients (SSPPD-ETS group). In the second period (April 2010–September 2012), gastrojejunostomy was performed with the greater curvature side-to-jejunal side anastomosis in 80 patients (SSPPD-STS group). After the surgery, the patients were monitored until hospital discharge, and afterwards, they were followed up in the outpatient clinic for up to 90 days. All data were collected prospectively in a computerized database and reviewed retrospectively. Informed consent was obtained from all patients preoperatively; this study was conducted in accordance with the ethical standards of the Committee on Human Experimentation of our institution. DGE was diagnosed according to the classification of the International Study Group of Pancreatic Surgery (ISGPS)25 as follows: grade A if a nasogastric tube (NGT) was required between postoperative day (POD) 4–7, reinsertion of the NGT was necessary owing to nausea and vomiting after removal by POD 3, or inability to tolerate a solid diet by POD 7 but with resumption by POD 14; grade B if an NGT was required from POD 8–14, reinsertion of the NGT was necessary after POD 7, or the patient could not tolerate unlimited oral intake by POD 14 but was able to resume a solid oral diet by POD 21; and grade C if nasogastric intubation could not be discontinued or had to be reinserted after POD 14 or if the patient was unable to maintain unlimited oral intake by POD 21. Surgical Technique The schema of the SSPPD-ETS, the conventional group procedure, and the SSPPD-STS, the study group procedure, are shown in Fig. 1. The stomachs were divided 2–3 cm proximal to the pyloric ring with more than 90 % of the stomach preserved in both procedures.19 In brief, both reconstruction groups underwent end-to-side pancreaticojejunostomy and hepatojejunostomy, and the jejunal loop was used for the gastrojejunostomy via an antecolic route. In all the patients in this study period, the gastrojejunostomy was reconstructed with antecolic reconstruction. The singular difference between
J Gastrointest Surg (2015) 19:1425–1432
the two groups was that in the SSPPD-ETS group, the gastric stump was anastomosed to the jejunal loop in an end-to-side fashion (Fig. 1a), whereas in the SSPPD-STS group, the jejunal loop was anastomosed to the greater curvature 5–10 cm proximal to the closed gastric stump, and the anastomosis was just the greater curvature, not the anterior nor the posterior wall of the stomach (Fig. 1b). The gastrojejunostomy was performed by a one-layer anastomosis using the Gambee technique of 4-0 monofilament absorbable sutures. The stomach is severed with a stapler and is oversewn with serosa. The opening of the anastomosis for each technique is about 5 cm length; therefore, the STS and the ETS are of same orifice size. Both groups were managed according to the same clinical pathway, such as removal of the NGT if the drainage amount
